| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| LAKESHORE BENEFIT GROUP INSURANCE3 Filed as: LAKESHORE BENEFIT GROUP INS BRK LLC | 301 ALBANY TURNPIKE CANTON, CT 06019 | HARTFORD LIFE AND ACCIDENT | $1K | — | $1K | 5.00% |
| LAKESHORE BENEFIT GROUP INSURANCE3 Filed as: LAKESHORE BENEFIT GROUP INS BRK LLC | 301 ALBANY TURNPIKE CANTON, CT 06019 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $2K | — | $2K | 10.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| HORIZON HEALTHCARE SERVICES EIN 22-0999690 NONE | Direct payment from the plan; Claims processing Service code 12 | — | $487K |
| I. E. SHAFFER & CO. EIN 22-1750854 NONE | Direct payment from the plan; Contract Administrator Service code 13 | — | $280K |
| NOVAK FRANCELLA EIN 61-1436956 NONE | Direct payment from the plan; Accounting (including auditing) Service code 10 | — | $43K |
| SUSANIN WIDMAN & BRENNAN, PC EIN 23-2265950 NONE | Legal; Direct payment from the plan Service code 29 | — | $34K |
| JOHN M. FOWLER LLC EIN 22-3789539 TRUSTEE | Direct payment from the plan; Trustee (individual) Service code 20 | — | $20K |
| CLEARY JOSEM & TRIGIANI, LLP EIN 23-2657967 NONE | Legal; Direct payment from the plan Service code 29 | — | $17K |
| MILLIMAN EIN 91-0675641 NONE | Consulting (general); Direct payment from the plan Service code 16 | — | $8K |
| UAW LOCAL 3170 EIN 27-5300521 NONE | Recordkeeping and information management (computing, tabulating, data processing, etc.); Direct payment from the plan Service code 15 | — | $8K |
Benefits declared on the Form 5500 main form (✓ = also has a Schedule A insurance contract; otherwise the benefit is funded out of plan assets or via a Schedule C TPA).
The plan reports several different headcounts depending on which form you read. Each one measures a different slice of the population.
| Active participants | 787 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 5 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 792 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental(3 contracts, 3 carriers) | HORIZON HEALTHCARE SERVICES, INC. | 819 | $176K |
| Vision | HORIZON INSURANCE COMPANY | 819 | $99K |
| Life insurance | HARTFORD LIFE AND ACCIDENT | 330 | $27K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 34 | $21K |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 34 | $21K |
| Stop-loss / reinsurancereinsurance | THE UNION LABOR LIFE INSURANCE COMPANY | 823 | $340K |
| Other | HARTFORD LIFE AND ACCIDENT | 330 | $27K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 823 | — |
Why the numbers differ. Form 5500 line 6 counts employees + retirees + beneficiaries; no dependents. Schedule A persons-covered counts everyone enrolled, including spouses and children, so it usually exceeds line 6 by 30-60% on a working-age workforce. The medical row is normally the broadest single line because it has the highest take-up; dental/vision/life often dip below it. Stop-loss / reinsurance contracts sometimes report the carrier's full underwriting pool rather than this filer's headcount; the row is shown for transparency but shouldn't be read as "people in this plan."
No prospect flags tripped on this filing.